Necrotizing gastritis due to Bacillus cereus in an immunocompromised patient

Neuroinvasive Bacillus cereus Infection in Immunocompromised Hosts: Epidemiologic Investigation of 5 Patients With Acute Myeloid Leukemia

Background

Bacillus cereus is a ubiquitous gram-positive rod-shaped bacterium that can cause sepsis and neuroinvasive disease in patients with acute leukemia or neutropenia.

Methods

A single-center retrospective review was conducted to evaluate patients with acute leukemia, positive blood or cerebrospinal fluid test results for B cereus, and abnormal neuroradiographic findings between January 2018 and October 2022. Infection control practices were observed, environmental samples obtained, a dietary case-control study completed, and whole genome sequencing performed on environmental and clinical Bacillus isolates.

Results

Five patients with B cereus neuroinvasive disease were identified. All patients had acute myeloid leukemia (AML), were receiving induction chemotherapy, and were neutropenic. Neurologic involvement included subarachnoid or intraparenchymal hemorrhage or brain abscess. All patients were treated with ciprofloxacin and survived with limited or no neurologic sequelae. B cereus was identified in 7 of 61 environmental samples and 1 of 19 dietary protein samples-these were unrelated to clinical isolates via sequencing. No point source was identified. Ciprofloxacin was added to the empiric antimicrobial regimen for patients with AML and prolonged or recurrent neutropenic fevers; no new cases were identified in the ensuing year.

Conclusions

B cereus is ubiquitous in the hospital environment, at times leading to clusters with unrelated isolates. Fastidious infection control practices addressing a range of possible exposures are warranted, but their efficacy is unknown and they may not be sufficient to prevent all infections. Thus, including B cereus coverage in empiric regimens for patients with AML and persistent neutropenic fever may limit the morbidity of this pathogen.

Extremely rare case of necrotizing gastritis in a patient with autoimmune hepatitis: A case report

BACKGROUND

Autoimmune hepatitis can cause liver fibrosis, liver cirrhosis, and hepatocellular carcinoma. Its treatment option include the use of steroids and/or immune-suppressive agents such as azathioprine. However, these drugs have some side effects. Thus, close follow-up is needed during treatment. Here, we present an extremely rare case of a patient with an autoimmune hepatitis who died from necrotizing gastritis during immunosuppressive treatment.

CASE SUMMARY

A 52-year-old female patient was diagnosed with autoimmune hepatitis. We treated this patient with immunosuppressive agents. High-dose steroid treatment was initially started. Then azathioprine treatment was added while steroid was tapering. Five weeks after the start of treatment, she visited the emergency room due to generalized abdominal pain and vomiting. After computed tomography scan, the patient was diagnosed with necrotizing gastritis and the patient progressed to septic shock. Treatment for sepsis was continued in the intensive care unit. However, the patient died at 6 h after admission to the emergency room.

CONCLUSION

In patients with autoimmune infections undergoing immunosuppressant therapy, rare complications such as necrotizing gastritis may occur, thus requiring clinical attention.

Acute gastric necrosis caused by a -hemolytic streptococcus infection: a case report and review of the literature

Acute necrotizing gastritis, which appears to be a variant of phlegmonous gastritis is the rarest cause of gastric necrosis. We report a case of a 57-year-old female patient with an acute necrotizing gastritis caused by a Group A β-hemolytic streptococcus. The case presented herein is of unusual interest because only a limited number of case reports on this etiology have been published. Diagnosing infectious necrotizing gastritis remains complex because of its rarity and nonspecific clinical presentation. Nevertheless, prompt diagnosis is of high importance because necrotizing gastritis can progress rapidly into a more advanced stage causing septic shock or even death. In our opinion, early resection of necrotic gastric wall combined with adequate antimicrobial therapy is the cornerstone in treatment of necrotizing gastritis. We will present a case in which adequate medical treatment was not successful.

A Case of Fulminant Bacillus cereus Lung Necrosis in a Preterm Neonate

Bacillus cereus is a ubiquitous Gram-positive rod seldom considered pathogenic in clinical isolates. However, it possesses multiple virulence factors explaining why it has been linked to fulminant and pyogenic infections in vulnerable hosts. Its recovery from sterile samples in immunocompromised patients cannot be disregarded. Premature infants would fall into this category. We describe the case of a neonate born at 26 weeks of gestational age, who died of a rapidly progressive B. cereus necrotizing pneumonia following suspected nosocomial acquisition. The rapidity of his course and the autopsy findings of necrosis with minimal inflammation suggest a toxin-mediated process. Pathologists should be aware of this pathogen and obtain proper microbiological samples in the presence of such autopsy findings, as the diagnosis may have infection-prevention implications in health-care settings.

Acute necrotising gastritis in a 14-year-old girl

A 14-year-old female patient presented with acute generalised abdominal pain and two attacks of non-bilious vomiting for 2 days. She visited the emergency department and at presentation she was pale, dyspnaeic and there was no jaundice. Abdominal examination showed moderate abdominal distension with generalised abdominal tenderness. The bowel sounds were negative on auscultation. Plain abdominal X-ray showed hugely distended stomach with no free air detected in the peritoneal cavity. During laparotomy there was huge distension and gangrene of the stomach involving the whole stomach up to the fundus. Total gastrectomy done with roux-en-y reconstruction of the gastrointestinal continuity. The histopathological study of the sample showed gastric necrosis.

Bacillus cereus Typhlitis in a Patient with Acute Myelogenous Leukemia: A Case Report and Review of the Literature

Bacillus cereus is a Gram-positive rod that is now recognized as a rare cause of frank disease in the neutropenic hematologic malignancy patient. Because this pathogen is rarely isolated in clinical specimens, no large studies exist to guide the management of these acutely ill patients. Individual case reports and case series exist in the literature describing various clinical manifestations of B. cereus in the neutropenic patient including bacteremia/septicemia, pneumonia, meningitis/encephalitis, hepatic abscesses, and gastritis. In this report, we describe a case of typhlitis caused by B. cereus in a 74-year-old female with recently diagnosed acute myelogenous leukemia (AML), and we summarize the available English language literature to draw tentative conclusions regarding the clinical manifestations of this organism.

Bacillus cereus bacteraemia: comparison between haematologic and nonhaematologic patients

Bacillus cereus bacteraemia can be severe, especially among patients with haematologic malignancy. We retrospectively reviewed first episodes of true B. cereus bacteraemia (more than one positive bottle plus signs of infection) at our institution between 1997 and 2013 with the aim to compare haematologic versus nonhaematologic patients and analyse episodes with complicated outcome. Among 56 episodes of positive-blood cultures for B. cereus, 21 were considered significant. Median age was 54 years (range 23-82 years). Ten patients (48%) had a haematologic malignancy; all were neutropenic at the time of B. cereus bacteraemia. Nonhaematologic patients were either intravenous drug users (n = 3, 14%), polytraumatized (n = 3, 14%) or had multiple chronic comorbidities (n = 5, 24%). Most episodes were hospital acquired (15, 71%). Sources of bacteraemia were intravascular catheter (n = 11, 52%), digestive tract (n = 6, 29%), drug injection (n = 3, 14%) and wound (n = 1, 5%). Adequate antibiotic therapy was provided to 18 patients (86%) during a median of 17 days (range 2-253 days). The intravascular catheter was removed in eight cases (42%). Three haematologic patients had a complicated course with neurologic complications (meningoencephalitis and cerebral abscesses). Complications appeared to be associated with catheter infection (100% of complicated cases vs. 29% of noncomplicated cases). In conclusion, B. cereus bacteraemia can have a complicated course in a subset of patients, mainly those with haematologic malignancy. Catheter infection may be associated with a worse outcome with frequent neurologic complications.

Epidemiologic Investigation of a Cluster of Neuroinvasive Bacillus cereus Infections in 5 Patients With Acute Myelogenous Leukemia

Background.  Five neuroinvasive Bacillus cereus infections (4 fatal) occurred in hospitalized patients with acute myelogenous leukemia (AML) during a 9-month period, prompting an investigation by infection control and public health officials. Methods.  Medical records of case-patients were reviewed and a matched case-control study was performed. Infection control practices were observed. Multiple environmental, food, and medication samples common to AML patients were cultured. Multilocus sequence typing was performed for case and environmental B cereus isolates. Results.  All 5 case-patients received chemotherapy and had early-onset neutropenic fevers that resolved with empiric antibiotics. Fever recurred at a median of 17 days (range, 9-20) with headaches and abrupt neurological deterioration. Case-patients had B cereus identified in central nervous system (CNS) samples by (1) polymerase chain reaction or culture or (2) bacilli seen on CNS pathology stains with high-grade B cereus bacteremia. Two case-patients also had colonic ulcers with abundant bacilli on autopsy. No infection control breaches were observed. On case-control analysis, bananas were the only significant exposure shared by all 5 case-patients (odds ratio, 9.3; P = .04). Five environmental or food isolates tested positive for B cereus, including a homogenized banana peel isolate and the shelf of a kitchen cart where bananas were stored. Multilocus sequence typing confirmed that all case and environmental strains were genetically distinct. Multilocus sequence typing-based phylogenetic analysis revealed that the organisms clustered in 2 separate clades. Conclusions.  The investigation of this neuroinvasive B cereus cluster did not identify a single point source but was suggestive of a possible dietary exposure. Our experience underscores the potential virulence of B cereus in immunocompromised hosts.

Acute gastric necrosis after routine oesophagogastroduodenoscopy with therapeutic argon plasma coagulation

A 56-year-old woman presented to the accident and emergency department with peritonitis 2 days after a routine oesophagogastroduodenoscopy. She was taken to theatre with the finding of gastric necrosis. Blood and peritoneal cultures grew group A haemolytic Streptococcus. Histology revealed normal vasculature, no volvulus but marked neutrophilia in the submucosa with an intact mucosa. The stomach was resected and the patient recovered in the intensive care unit but overwhelming acidosis progressed to multiorgan failure and treatment was eventually withdrawn. Acute phlegmonous gastritis has been well described in the literature but mainly before the advent of antibiotics. The most common organism is group A haemolytic Streptococcus (commonly found in throat infections) and predisposing factors include instrumentation. Should antibiotics be given at the start of an oesophagogastroduodenoscopy and should routine procedures be delayed if active upper respiratory tract infections are present?

Acute Dilatation, Ischemia, and Necrosis of Stomach without Perforation

Acute gastric dilatation can have multiple etiologies which may lead to ischemia of the stomach. Without proper timely diagnosis and treatment, potentially fatal events such as gastric perforation, haemorrhage, and other serious complications can occur. Here we present a 36-year-old man who came to the casualty with pain abdomen and distension for 2 days. Clinically, abdomen was asymmetrically distended more in the left hypochondrium and epigastrium region. Straight X-ray abdomen showed opacified left hypochondrium with nonspecific gaseous distension of bowel. Exploratory laparotomy revealed dilated stomach with patchy gangrene over lesser curvature and fundic area. About 4 litres of brownish fluid along with semisolid undigested food particles was sucked out (mainly undigested pieces of meat). Limited resection of gangrenous areas and primary repair were done along with feeding jejunostomy. Necrosis of the stomach was confirmed on histopathology. The patient recovered well and was discharged on the tenth postoperative day.

Bacillus cereus catheter related bloodstream infection in a patient with acute lymphoblastic leukemia

Bacillus cereus infection is rarely associated with actual infection and for this reason single positive blood culture is usually regarded as contamination . However it may cause a number of infections, such catheter-related bloodstream infections. Significant catheter-related bloodstream infections (CRBSI) caused by Bacillus spp. are mainly due to B. cereus and have been predominantly reported in immunocompromised hosts. Catheter removal is generally advised for management of infection. In this report, catheter-related bacteremia caused by B. cereus in a patient with acute lymphoblast c leukemia (ALL) in Istanbul Medical Faculty was presented.

Bacillus cereus, a volatile human pathogen

Bacillus cereus is a Gram-positive aerobic or facultatively anaerobic, motile, spore-forming, rod-shaped bacterium that is widely distributed environmentally. While B. cereus is associated mainly with food poisoning, it is being increasingly reported to be a cause of serious and potentially fatal non-gastrointestinal-tract infections. The pathogenicity of B. cereus, whether intestinal or nonintestinal, is intimately associated with the production of tissue-destructive exoenzymes. Among these secreted toxins are four hemolysins, three distinct phospholipases, an emesis-inducing toxin, and proteases. The major hurdle in evaluating B. cereus when isolated from a clinical specimen is overcoming its stigma as an insignificant contaminant. Outside its notoriety in association with food poisoning and severe eye infections, this bacterium has been incriminated in a multitude of other clinical conditions such as anthrax-like progressive pneumonia, fulminant sepsis, and devastating central nervous system infections, particularly in immunosuppressed individuals, intravenous drug abusers, and neonates. Its role in nosocomial acquired bacteremia and wound infections in postsurgical patients has also been well defined, especially when intravascular devices such as catheters are inserted. Primary cutaneous infections mimicking clostridial gas gangrene induced subsequent to trauma have also been well documented. B. cereus produces a potent beta-lactamase conferring marked resistance to beta-lactam antibiotics. Antimicrobials noted to be effective in the empirical management of a B. cereus infection while awaiting antimicrobial susceptibility results for the isolate include ciprofloxacin and vancomycin.

Biology and taxonomy ofBacillus cereus,Bacillus anthracis, andBacillus thuringiensis

Three species of the Bacillus cereus group (Bacillus cereus, Bacillus anthracis , and Bacillus thuringiensis ) have a marked impact on human activity. Bacillus cereus and B. anthracis are important pathogens of mammals, including humans, and B. thuringiensis is extensively used in the biological control of insects. The microbiological, biochemical, and genetic characteristics of these three species are reviewed, together with a discussion of several genomic studies conducted on strains of B. cereus group. Using bacterial systematic concepts, we speculate that to understand the taxonomic relationship within this group of bacteria, special attention should be devoted also to the ecology and the population genetics of these species.